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I make time for things that bring me joy—cooking, spending time with friends, and trying new things. Candles, relaxing music, and a nice cup of hot tea does wonders.

~ Christina Tsai '21

Take Care

Geisel advocates a paradigm shift in advancing the health and well-being of medical students.

By Susan Green

Wellness entered common language usage during the mid-1650s to describe an absence of illness. By the 19th century, though wellness encompassed diet, exercise, and other lifestyle choices vital to maintaining good mental and physical health, the ethos was not widely accepted until the 1950s when the movement gained traction in the broader population. And while some of the practices advocated at that time were looked down upon by modern medicine, they are now the basisof an evidence-based wellness movement taking root at medical schools nationwide.

Medical students at risk

According to a report from the Association of American Medical Colleges (AAMC), burnout, a persistent trend among physicians and medical students, is on the rise. Medical students have increased odds of depressive symptoms over those of medical residents and physicians, and they have a higher prevalence of psychological distress compared to the general population and age-matched peers. Nationally, nearly one-third of medical students report symptoms of depression and more than one in ten have considered suicide.

Susan Green is a senior writer for Dartmouth Medicine.

A longstanding, measurable problem with complex origins, burnout receives a lot of attention—yet it along with wellness and mental health often get intertwined in confusing ways.

Wellness, more than the absence of disease, is defined in the Merriam-Webster Dictionary "as the state of being healthy in mind, body, and spirit as the result of deliberate effort." Even with this straight forward definition interpretations abound. For many, this deliberate process of self-care includes a number of dimensions—emotional, occupational, physical, social, spiritual, intellectual, and ethical.

"If you ask five people to define wellness, you often get five different answers," says Caitlin Maher, MA, Geisel's wellness coordinator, who works closely with Matthew Duncan, MED '01 to develop and oversee the medical school's wellness initiatives.

Maher has spent her career making sure students have what they need in order to have a successful and positive educational experience, whether through the advising process, talking with them about their wellness needs, or connecting them with community resources.

When she arrived at Geisel two years ago, she asked students about existing wellness initiatives—what the school was doing well and whether or not student needs were being met. She found a high proportion of students who self-identified as needing mental health services, but reluctant to reach out for help because of time constraints accessing care and a fear of professional consequences—seeking mental healthcare is often viewed as a sign of weakness. Others expressed a need for increased suicide prevention awareness. It was clear to Maher that seeking help for mental health issues needed to be normalized. "That's when Matt and I began working on expanding Geisel's wellness efforts," she says.

An assistant professor of psychiatry and an associate dean of student affairs, Duncan thinks it is important to make a distinction between mental health and wellness, though they are interconnected. Mental health includes our emotional, psychological, and social well-being—it affects how we think, feel, and act. It also helps determine howwe relate to others, make choices, andhandle stress.

Not all stressors lead to anxiety and depression. In a learning environment, acute stress can be internalized as healthy motivation to perform well and achieve success academically, personally, and professionally. But unrecognized chronic stress turns off the learning process, creativity, and high-level thinking in favor of survival.

Personal issues aside, medical students overloaded with course work and other pressing obligations may unintentionally ignore their own well-being. For example, every eight weeks, third- and fourth-year students are immersed in new demanding physical and cognitive environments where they are constantly assessed while preparing for robust examinations. In addition, they are going through the normal stressors of emerging adulthood, which is challenging enough, but they are also internalizing what it means to be a doctor while forging their own professional identity. Imagine starting a new job every two months that ends with a formal evaluation and an exam that your career depends upon. Survival may take precedence over self-care.

"Having to integrate all of that in a strength-based way is tough," Duncan says. "And add to that the unique aspects we have here at Geisel because of our rural location—our students travel to California, Arizona, Montana, and Alaska for these eight-week rotations. Geography plus the demands of medical education makes timely access to, and continuity of, mental healthcare difficult."

To me, wellness is a matter of priorities. I get on my yoga mat every single day, even if it's just for a couple minutes. I also significantly limit my cell phone use.

~ Olivia Sacks '19

There is also the stigma of seeking these services because, historically, mental health and self-regard are linked.

Medicine is a culture with strong beliefs about how physicians should behave. Advocating for patients rather than themselves is an entrenched belief that is passed on to medical students. Not all mental health symptoms are impairing for everyone, but ignoring signs pointing to a need for self-care can manifest in unexpected ways and be detrimental to patient care.

Deliberate Effort

"We dedicated the past two years to establishing a culture of wellness within the medical student community," Maher says. "And because of the broad definition of wellness, we honed-in on three areas to better focus our efforts—encourage students to embrace stress-related growth (such as developing a physician identity and finding mentors), increase stress management skills (yoga, meditation, exercise, reflection), and reduce unnecessary stress in the learning environment."

Since then, Geisel has progressed from a variety of one-off wellness events without focused goals, to a structured wellness program, a charter workgroup to address student wellness needs, and a new student government framework that creates a pipeline for student information between the administration and students. All of these efforts contribute to the medical school's goal of training complete future physicians.

Two student government-elected wellness representatives from each class year and the Geisel Student Mental Health Charter Group work collaboratively with Dartmouth's Dick's House Counseling Center to expand access to mental healthcare for medical students.

"Caitlin and Matt have done an amazing job spearheading this," says Heather Earle, PhD, director of counseling services at Dick's House. "We now have students on the committee who are passionate and spend a lot of time and energy on this work."

Both Maher and Duncan are part of the work group, and Maher works closely with elected representatives from the Student Needs and Assistance program (SNAP) to support student initiatives. SNAP representatives, who each serve for four years, are tasked with looking out for peers who may be susceptible to impairment. They also appraise ongoing wellness initiatives and organize new programming to increase students' stress management skills.

Matthew Stanton '22 and Colin McLeish '22 represent their first-year class. As SNAP representatives, they hold regular office hours, check in one-on-one with peers, and meet classmates for coffee to chat about school and life in general. Large-scale population studies have shown that having positive relationships can lessen depression in the future. "Until very recently, little has been done to address wellness in medical education," McLeish says. "I am driven by the possibility that personal wellness may be valued as highly as professional achievement."

Taking care of yourself mentally, physically, and emotionally is critical for sustaining a productive career in medicine, Stanton says. "I like being a SNAP rep because I have an identified role in fostering a resilient and supportive community at Geisel."

Matthew Duncan MED '01, associate dean of students, and Caitlin Maher, MA, Geisel's wellness coordinator.

Though not wellness representatives, Steven Conn '22 and Christina Tsai '21, are equally committed to student well-being and each lead weekly meditation and yoga sessions, respectively.

Conn believes meditation is an important counterbalance to the corrective mindset pervasive in medicine. "Remaining totally fixed in this corrective disposition can dysregulate our mood and narrow our thinking. Sitting meditation invites us to explore what emerges when we drop that corrective for gradually longer moments," he says.

As a student yoga teacher for Geisel's yoga program, which offers subsidized two-dollar classes every Sunday, Tsai is working with Maher and others to expand the program. "Yoga has brought me a lot of peace and sense of grounding—an outlet for centering myself amidst the demands of medical school and the stresses of finding my way in life," she says. "When my students step onto their mats, I hope for them to release judgement, connect with themselves honestly, and remember that they are worthy regardless of how they perform at school or in other external measures—we are all capable of making an impact caring for others, starting with ourselves."

Yoga, mindfulness, and meditation may carry a whiff of New Age fads, but there is evidence proving they work to reduce stress—a study of 298 college students found that Transcendental Meditation helped students reduce stress and improve coping strategies—not clinical mental disorders, which are distinct from stress. According to the National Institutes of Health (NIH), the regular practice of yoga benefits mood and the physiological response to stress.

James Stahl, MD, MPH, section chief of general internal medicine at Dartmouth-Hitchcock and an associate professor of medicine, is an advocate of mind-body medicine, which focuses on the interactions between the brain, the body, the mind, and behavior. The research in this field, he says, has reached a point where the evidence that it works is overwhelming—for example, mind-body therapies can reduce both psychological and physical stress and many NIH-funded trials suggest that these tools can help relieve pain and suffering, reduce inflammation, improve cognition and slow cognitive decline, and improve survival in many diseases.

An early morning jog and micro-moments of stress release throughout the day—reading a few pages from a novel and meditating for three to five minutes whenever possible—have a remarkable effect on my perspective.

~ Patrick Tolosky '21

Stahl teaches a variety of stress management techniques in a relaxation and resiliency elective he offers to medical students as well as residents and physicians. "Not every tool is right for everyone—you have to use what works best for you. A strength of this program is that it weaves together a number of tools ranging from meditation to yoga to cognitive restructuring. Meditation takes practice, but it is something that will be with you throughout your life."

Cognitive restructuring focuses on modulating cognitive distortions—non-productive thought patterns such as black and white thinking, catastrophizing, and fear of failure are common among medical students. But practical steps can be taken to reduce and manage a distorted mindset—the first step is recognizing the signs of overload.

Once recognized, one of the easiest things to do to calm yourself, Stahl says, is to voluntarily control your breathing. Breathing techniques stimulate the vagus nerve, one of the cranial nerves connecting the brain to the body that slows heart rate, producing a calm mental state that sets the stage for learning how to break out ofa non-productive mindset.

Beyond common stressors such as sleep deprivation, academic pressures, and financial struggles, medical students often find themselves in clinical situations they may not be prepared to face—as aspiring physicians, they haven't quite grown into their professional identity. Not acknowledging the stress of observing or participating in life and death decisions can foster frustration, anger, and burnout.

William Nelson, PhD, who teaches ethics and is a professor of psychiatry and community and family medicine, believes ethics plays a leading role in clinical care. He thinks it is critical for medical students to become aware of moral distress on both an individual and healthcare team level.

When not spendingtime with friends, I restore myself with time alone walking, writing,and reading.

~ Colin McLeish '22

"Consider the many ethical conflicts that arise in end of life decision making—knowing the right thing to do when there is ethical uncertainty or conflicting positions can result in moral distress," he says. "It's important for the healthcare team to debrief and review their decisions after handling a troubling ethics case."

Nelson says moral distress, the disconnect between acting in accordance with ethical and professional values and the actual work environment, can have a negative effect on patient care and healthcare organizations. Administrators need to acknowledge this reality and develop and implement specific effective strategies for addressing ethical issues. Fostering an ethics grounded culture of medicine needs to start at the top, in both medical schools and healthcare systems, in order to optimize physician well-being.

"Recognition is powerful and as students navigate these environments they get a refined sense of what is essential to their survival and it's learned on the ground in real time," says Duncan who teaches a third-year session on resilience. "Often signs of distress may be evident before a problem is recognized and by then it may be too late, but when someone recognizes what they are doing to foster resiliency or recalls past experiences they can draw from, it's strengthening."

Maher and Duncan are collaborating with the American Foundation for Suicide Prevention and Earle, Dartmouth's director of counseling services, to implement an anonymous, mental health screening program to connect students with a designated counselor within 24-hours if their questionnaire ranks as in crisis. Questionnaire results are tiered into a 24-, 48-, or 72-hour response window based on the acuity of the symptoms and feelings reported. "This platform is an effort to bring mental health awareness to our students—to capture students who may not self-identify or have self-awareness around their mental health needs, and connect these students to resources for help," Maher explains.

Recognizing that some medical students may need a place where they can talk openly and without judgement about what they are experiencing, its level of impact, and how it taps into other experiences they may be unaware of—Patrick Tolosky and Emily Masterson, both second-year Geisel students, created a space devoted to intentional reflection and thought-sharing where students can talk about their medical school experience. "Social gatherings are vitally important, but it's not always easy to bring up our struggles when we simply want to relax," Tolosky says. "Our once-a-month meetings allow us to have open, honest, and wide-ranging conversations with one another—afterwards, I always feel a little more grounded and connected to my classmates."

Earle says implementing these wellness initiatives and promoting student self-care is a very important part of patient care and patient safety—a physician who is not struggling with mental health issues, or burned out, is energized and engaged in direct patient care, healthcare system improvement, and makes fewer errors in judgement.

"I think this is a particular cultural moment in medical education," Stahl says. "But teaching people tools and techniques is only part of the answer. The fundamental structure needs to be changed—it's good to prepare medical students for the profession and to set the stage for change, but unless the culture changes there will always be problems."

Paradigm Shift

Well-being has emerged as the zeitgeist of academic medicine, and the AAMC has charged medical schools, and is holding them accountable, to make wellnessa priority.

SNAP representative Matthew Stanton '22
and Izhar Mbarani '22 meet for coffee.

Physicians and trainees face complex structural and cultural issues that have impeded progress in creating environments that facilitate well-being in both medical schools and healthcare systems. And stressors attributed to these issues are completely different from those of practicing medicine even five years ago.

Until recently, burnout and resilience in medical education has been focused on the vulnerability of individuals, rather than the existing culture. Cultural factors include academic workload, both formal and informal; whether medical students share the values of the organization and its leadership; rewards and recognition—the alignment of assessments and rewards with the work being done; and the importance of community support.

Geisel has been working diligently toward addressing these issues via curricular changes, some of which will be implemented this fall. By streamlining the academic calendar and incorporating evidence-based pedagogy to make learning more efficient and enriching, students will have more flexible time for electives and experiences that promote professional growth—all reducing unnecessary stressors in the curriculum. Flexible, accessible, and informal mental health services have also been established.

Catherine Pipas, MD, MPH '11, a professor of community and family medicine at Geisel, and a family physician, has spent the past several years thinking about this cultural shift toward physician and student well-being. She teaches an elective course for medical students focused on twelve evidence-based strategies she has researched and written about in her book A Doctor's Dozen: 12 Strategies for Personal Health and A Culture of Wellness. Defining wellness in a holistic way, she has linked components of self-awareness, self-care, and self-improvement into a toolkit for modeling health and building resilience. And this year, Pipas is also teaching the course for students, staff, and faculty at Dartmouth's Tuck Schoolof Business.

For stress relief, I enjoy listening to music, working out, reading, and eating.

~ Stephen Conn '22

"Personal well-being requires a real paradigm shift because of the traditional way medicine is taught and practiced and the way in which the healthcare system is designed—overcoming this long-term culture is challenging, but it can happen when personal needs are acknowledged and embraced as critical to our effectiveness as physicians," Pipas says. "The shift in thinking is that taking care of ourselves as health professionals, allows each of us to take better care of our patients."

It can be argued that wellness initiatives and curricular modifications are hyper-protective measures, but these stress management techniques work and once learned they become lifelong skills to achieving wellness. With that being said, Duncan believes a majority of medical students succeed in spite of the crazy pressure—many intuitively understand which coping mechanisms work best for them and they underestimate their true flexibility and resilience—but there is always roomfor improvement.

"We know we have a gap in delivering formal mental healthcare to our population based on both national and local needs—we are looking at changes in the learning environment to see where improvements have been made and where unnecessary stressors are still present, and looking at the overarching structure of healthcare with our clinical partners to examine top down organizational changes that need to be made," he says. "This is our three-year plan to a better place.

"The basic premise that is important to recognize in the context of medical education, is that mental health conditions common in the general population—depression, anxiety, and suicidal ideation, are well known to exist at a higher rate in medical students," Duncan reiterates. "But in wellness, energy and joy are two things that are preserved. People feel an impulse to move toward their work rather than feeling depleted by it.

"Given the complexities of modern medicine—knowledge of basic science, clinical practice, and healthcare delivery improvement—I think Geisel is doing a good job training complete physicians who are resilient and well enough to practice medicine for the duration of their careers, and yet, we can do even better."

If you'd like to offer feedback about this article, we'd welcome getting your comments at DartMed@Dartmouth.edu.

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